Your quest to purchase a new car begins with an identification of the factors important to you. As you conduct a search of cars that rate high on those factors, you collect evidence and try to understand the extent of that evidence. A report that suggests a certain make and model of automobile has high mileage is encouraging. But who produced that report? How valid is it? How was the data collected, and what was the sample size?

In this Assignment, you will delve deeper into clinical inquiry by closely examining your PICO(T) question. You also begin to analyze the evidence you have collected.

To Prepare:

• Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry.
• Develop a PICO(T) question to address the clinical issue of interest you identified in Module 2 for the Assignment. This PICOT question will remain the same for the entire course.
• Use the key words from the PICO(T) question you developed and search at least four different databases in the Walden Library. Identify at least four relevant systematic reviews or other filtered high-level evidence, which includes meta-analyses, critically-appraised topics (evidence syntheses), critically-appraised individual articles (article synopses). The evidence will not necessarily address all the elements of your PICO(T) question, so select the most important concepts to search and find the best evidence available.
• Reflect on the process of creating a PICO(T) question and searching for peer-reviewed research.

Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews

Create a 6- to 7-slide PowerPoint presentation in which you do the following:

• Identify and briefly describe your chosen clinical issue of interest.
• Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest.
• Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected.
• Provide APA citations of the four relevant peer-reviewed articles at the systematic-reviews level related to your research question. If there are no systematic review level articles or meta-analysis on your topic, then use the highest level of evidence peer reviewed article.
• Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research. Be specific and provide examples.

Assessing patients with symptoms related to the disorders you are exploring this week pose some particular challenges for which the PMHNP should be prepared. Disruptive, impulse-control, and conduct disorders may involve aggressive outbursts, anger, deceitfulness, and unpredictability. Eliciting the needed interview and history data requires special care, self-control, and deliberateness on the part of the clinician. Several structured or semi-structured clinical interview tools exist for patients and, in the case of minors, for parents as well.

For this Assignment, you will be assigned to a case study by your Instructor and will need to complete a Comprehensive Psychiatric Evaluation on the patient in the case. The case will be related to any of the disruptive, impulse-control, conduct, dissociative, or somatic symptom-related disorders.

To Prepare:

• Review this week’s Learning Resources      and consider the insights they provide.
• Download the Comprehensive      Psychiatric Evaluation Template, which you will use to complete this      Assignment. Also review the Comprehensive Psychiatric      Evaluation Exemplar to see an example of a completed evaluation

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

CC (chief complaint): 

HPI: 

Past Psychiatric History: 

· General Statement: 

· Caregivers (if applicable):

· Hospitalizations: 

· Medication trials: 

· Psychotherapy or Previous Psychiatric Diagnosis: 

Substance Current Use and History: 

Family Psychiatric/Substance Use History: 

Psychosocial History: 

Medical History: 

· Current Medications: 

· Allergies: 

• Reproductive Hx: 

ROS: 

· GENERAL: 

· HEENT: 

· SKIN: 

· CARDIOVASCULAR: 

· RESPIRATORY: 

· GASTROINTESTINAL: 

· GENITOURINARY: 

· NEUROLOGICAL: 

· MUSCULOSKELETAL: 

· HEMATOLOGIC: 

· LYMPHATICS: 

· ENDOCRINOLOGIC: 

Physical exam: if applicable

Diagnostic results: 

Assessment

Mental Status Examination: 

Differential Diagnoses: 

Reflections:

References

To Prepare:

• Review this week’s Learning Resources and consider the      insights they provide.
• Download the Comprehensive Psychiatric Evaluation      Template, which you will use to complete this Assignment. Also review the      Comprehensive Psychiatric Evaluation Exemplar to see an example of a      completed evaluation document. 
• you will be assigned to a specific video case study for      this Assignment. View your assigned video case, keeping the requirements      of the documentation template in mind.
• Consider what history would be necessary to collect      from this patient.
• Consider what interview questions you would need to ask      this patient.
• Identify at least three possible differential diagnoses      for the patient.

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

• Subjective: What      details did the patient provide regarding their chief complaint and      symptomology to derive your differential diagnosis? What is the duration      and severity of their symptoms? How are their symptoms impacting their      functioning in life? 
• Objective: What      observations did you make during the psychiatric assessment?  
• Assessment: Discuss      the patient’s mental status examination results. What were your      differential diagnoses? Provide a minimum of three possible diagnoses with      supporting evidence, listed in order from highest priority to lowest      priority. Compare the DSM-5 diagnostic criteria for each differential      diagnosis and explain what DSM-5 criteria rules out the differential      diagnosis to find an accurate diagnosis. Explain the critical-thinking      process that led you to the primary diagnosis you selected. Include      pertinent positives and pertinent negatives for the specific patient case.
• Reflection notes: What      would you do differently with this client if you could conduct the session      over? Also include in your reflection a discussion related to      legal/ethical considerations (demonstrate critical thinking beyond      confidentiality and consent for treatment!), health promotion and disease      prevention taking into consideration patient factors (such as age, ethnic      group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural      background, etc.).

 Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. 

• Review this week’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Post 1

Diedra S

Ethics

According to Fouka & Mantzorou ( 2011) It is said that ethics is the branch of philosophy which deals with the dynamics of decision making concerning what is right and wrong (Fouka & Mantzorou, 2011, p. 4).  As a nurse we are advocates to our patients and must have respect for all and provide care in a dignified manner.  When nurses participate in research they have to cope with three value systems, society, nursing and science (Fouka & Mantzorou, 2011, p. 4).  

Significant Ethical Issues

Ethical consideration tells us how we should conduct research, legal guidelines tell us how we are required to conduct research (Houser, 2018, p. 50).  When planning a research project it is important to consider if any harm will come to the participants, and the researcher should evaluate the possible harms and then have those potential harms removed. 

Research with vulnerable populations is just one ethical issue one might face as a researcher.  Persons with diminished autonomy sometimes are regarded as vulnerable or as a member of the vulnerable population, and these groups may contain some individuals who possess limited autonomy ( that is, they cannot fully participate in the consent process) for example children, individuals with dementia and other cognitive disorders, prisoners and pregnant women (Houser, 2018, p. 55).  

Research of minors falls into the category of a vulnerable population and when proposing a research study with children as participants, the Institutional Review Board (IRB) has to consider what the potential risks, benefits and pain or discomfort the child participant might have.  In assessing the risks and potential benefits the IRB should consider the circumstances of the children to be enrolled in the study-for example their health status, age and ability to understand what is involved in the research as well as potential benefits to subjects, other children with the same disease or condition, or society as a whole (“Children,” 2016, para. 3).  What happens when the research is on sexual health?  All states and Washington, DC have laws in place that allow minors to seek care and consent for themselves regarding their own sexual health. Of the 50 states and DC, there are 31 states that will allow for the minor to consent for HIV and STI treatment and prevention.  Despite these supportive HIV/STI care access policies for youth, and an ethical context that supports HIV/STI prevention, controversy about parental permission and minors “ maturity” remain in research (Brawner & Sutton, 2018, p. 545).  

Another ethical issue in research is the matter of privacy and confidentiality.  Privacy is the control over the extent, timing and circumstances of sharing oneself ( physically, behaviorally or intellectuality) with others and confidentiality pertains to the treatment of information that an individual has disclosed in a relationship of trust and with the expectation that it will not be divulged to others without permission in ways that are inconsistent with the understanding of the original disclosure (“Privacy,” 2019, para. 6).  Protocols should be implemented that allows for minimal identification about the research participants and for privacy it is essential to look into culture norms as some cultures are more private than others.

How do these issues compare to issues already seen in nursing practice

 For most of my career I worked in an inner-city academic facility and every shift the medical and nursing staff wrestled with informed consent where minors were concerned.  A young girl could present to the ER to be tested for STIs and pregnancy and would be able to consent for herself.  The dilemma came into play when the pregnancy test was positive.  She is a minor, she is able to consent for herself but how was I, a RN morally and ethically leave that ER without notifying her parent.  It was situations like this where social services would be called in.  The facility has a social worker assigned to the ER 24 hours a day, 7 days a week.  This issue was not a one off, it happened on most shifts that I worked.

            Providing privacy and maintaining confidentiality for patients is something that everyone working in healthcare has to do. We all take classes in HIPPA and have patients sign a confidentiality form stating that we will not disclose their medical information to anyone that is not listed on their privacy form.  In the community clinic we do this for every patient at every visit.  At times maintaining confidentiality seems futile because the clinic is an a very small rural area where everyone seems to know each other, but as futile as it seems the clinic does an excellent job of providing confidentiality. 

References

Brawner, B. M., & Sutton, M. Y. (2018). Sexual health research among youth representing minority populations: To waive or not to waive parental consent. Ethics & Behavior, 28(7), 544-559. http://dx.doi.org/10.1080/10508422.2017.1365303

Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing? Health Sciences Journal, 5(1), 3-14. Retrieved from https://search-proquest-com.ezp.waldenulibrary.org/docview/845921674/fulltextPDF/54E10B7826584C16PQ/1?accountid=14872

Houser, J. (2018). Nursing Research. Reading, Using and Creating Evidence (4 ed.). Burlington, MA: Jones & Bartlett Learning.

Privacy and confidentiality. (2019). Retrieved from https://www.research.uci.edu/compliance/human-research-protections/researchers/privacy-and-confidentiality.html

Special protections for children as research subjects. (2016). Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/guidance/special-protections-for-children/index.html

POST 2

Lodian T

Ethical Issues Relevant to the DNP- or PhD-Prepared Nurse

Ethical issues in clinical practice are increasingly problematic for nurses in almost all disciplines. As nurses, one encounters ethical challenges from being an administrator’s nurse to a bedside nurse or even advanced practice registered nurse. Nurses sometimes are often uncomfortable in addressing certain ethical issues they encounter in patient care. Some of the ethical challenges the DNP and Ph.D. prepared nurse faces are professionals, patient confidentiality breaches, right to privacy, and end-of-life decision-making (Larkin et al., 2019). The decision making on how resources are spent in managing a particular illness poses a moral issue. The decisions and choices about which medications and treatment options may prolong a patient life is an ethical dilemma frequently encountered (Haahr et al., 2020). The fact is, at times, some patients are not in a position to afford some of these treatments.

The nursing shortage and staffing inadequacies create a stressful and ethical issue. Without adequate staffing, it is challenging to meet professional practice’s ethical standards (Larkin et al., 2019). Understaffing creates systematic stress on organizations and on many nurses trying to meet each patient’s needs. The primary responsibility of protecting each patient’s rights is a challenge every day as deciding whom to care for first sometimes poses an ethical issue. As we know, today’s healthcare environment is driven by demands in providing high-quality care and managing costs. Yet, nurses seem to be doing more and more with limited staffing and having to questions the care at times provided as not adequate.

Issue Encountered in Practice

The ethical principle of respect involves understanding the differences of opinion of a patient and their families. The ethical challenges encountered depend on the nurse’s role (Sabone et al., 2020). The daily pressure of caring for patients with an advanced illness poses a challenge when deciding which care a patient should receive. According to Mehdipour-Rabori et al. (2019), ethical issues occur in healthcare every day where the profound moral of right or wrong comes into question and underlines the professional decision-making that benefits the patients. For instance, as a critical care nurse, one often faces suffering head-on and might question the balance between the value of attempts to preserve a patient’s life. This, to many, may appear as prolonging anguish and yield no beneficial outcome. Naturally, all healthcare team members, including nurses, can be affected by ethical decisions. Addressing ethical issues sometimes can prove to be exhausting when trying to work through ethical problems.

Another issue is the end of life care. Haahr et al. (2020) cited far too often, end-of-life ethical issues are not thoroughly discussed with care teams or families, which creates a stressful environment when providing care. Jakobsen and Sorlie (2016) state as the healthcare system continues to change, other ethical issues of importance may need to be explored. Of course, ethical issues will differ depending on the practice setting, patient population, and needs within society.

References

Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 27, 258-272. https://doi.org/10.1177/096973 3019832941

Jakobsen, R., & Sorlie, V. (2016). Ethical challenges. Nursing Ethics, 23, 636-645. https://doi.org/10.1177/0969733015580810

Larkin, M. E., Beardslee, B., Cagliero, E., Griffith, C. A., Milaszewski, K., Mugford, M. T., Myerson, J. M., Ni, W., Perry, D. J., Winkler, S., & Witte, E. R. (2019). Ethical challenges experienced by clinical research nurses: A qualitative study. Nursing Ethics, 26, 172-184. https://doi.org/10.1177/0969733017693441

Mehdipour-Rabori, R., Dehghan, M., & Nematollahi, M. (2019). Nursing students’ ethical challenges in the clinical settings: A mixed-methods study. Nursing Ethics, 26, 1983-1991. https://doi.org/10.1177/0969733018810766

Sabone, M., Mazonde, P., Cainelli, F., Maitshoko, M., Joseph, R., Shayo, J., Morris, B., Muecke, M., Wall, B. M., Hoke, L., Peng, L., Mooney-Doyle, K., & Ulrich, C. M. (2020). Everyday ethical challenges of nurse-physician collaboration. Nursing Ethics, 27, 206-220. https://doi.org/10.1177/0969733019840753

POST 3

Nichole C

Theoretical Framework for a Practice Problem

The article, ‘The gut microbiome in coronary artery disease and heart failure: Current knowledge and future directions,’ links sequenced-altered gut microbiota to cardiovascular disease. If understanding how altered gut bacteria triggers cardiovascular disease then the knowledge gained may improve clinical practice for CAD and heart failure patients. This research article does not address the “how-to” of a practice problem but identifies a knowledge gap in the understanding of the gut-heart connection and contributes to building a nurse’s body of knowledge (Gray, Grove, & Sutherland, 2017). There is no identified nursing theory the authors of the article use to guide their research. They use genetic sequencing and bioinformatics methodologies to comprise a gut microbiome profile with the active metabolites and their function and how they impact cardiovascular structure and function (Trøseid, Andersen, Broch, & Hov, 2020).

Insights into Quality-of-Life Theory

The nursing framework I used was the Quality-of-Life theory to help me understand the gut-heart axis phenomenon. Based on a synthesis of five nurse scholars’ theories, the Quality-of-Life theory can be defined as an intangible, subjective perception of one’s lived experience (Plummer & Molzahn, 2009). This definition is appropriate for contemporary nursing in that it embraces a perspective in which aspects of quality of life are intertwined and not divisible into discrete parts like health theory (Plummer & Molzahn, 2009). The Quality-of-Life theory encompasses the nursing practice involving care for the whole persons and their environment, rather than selected parts of their health (usually the physical aspect when talking about health). The Quality-of-Life theory is important to nursing knowledge development because it guides the art of practice.

Application of Theory

I think this theory can guide quality research for the gut-heart axis concept but since the research didn’t start with a solid nursing theory it was difficult to apply the theory afterwards. When researchers communicate clearly about how a theory was applied in their studies, others can synthesize evidence more readily across studies where the same theory was used, and by doing so, researchers can build scientific knowledge more efficiently than if they were not theory guided (Lor, Backonja, & Lauver, 2017). I believe the Quality-of-Life theory allows nurses to build a framework that is critical in producing the best evidence-based research. As nurse researchers, we must translate the best evidenced-based research into clinical practice so we can improve the quality of life for our patients.

References

Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.

Lor, M., Backonja, U., & Lauver, D. R. (2017). How could nurse researchers apply theory to generate knowledge more efficiently?. Journal of Nursing Scholarship, 49(5), 580-589. 

Plummer, M., & Molzahn, A. (2009). Quality of life in contemporary nursing theory: A concept analysis. Nursing Science Quarterly, 22(2), 134-140.

Trøseid, M., Andersen, G. Ø., Broch, K., & Hov, J. R. (2020). The gut microbiome in coronary artery disease and heart failure: Current knowledge and future directions. EBioMedicine, 52, 102649.

POST 4

Pamela J

Theoretical Framework

          The key concepts are defined in this writer’s research by a theoretical framework, examines relations between the concepts, and, based on the literature review, discusses relevant theories (Gray et al., 2197). This framework is critical and is present in qualitative, quantitative, or mixed methods (Gray et al., 2017).

Article Identified

          A Blueprint for Leadership During Covid-19: Minimizing Burnout and Moral Distress among the Nursing Workforce (Rosa et al., 2020) is an article chosen to look at nursing burnout during the ongoing pandemic. The nursing workforce is exposed to increased stressors that lead to burnout, including; limited resources, increased job expectations, and increasing spiritual, mental, emotional, and physical distress and exhaustion. The primary cause of burnout is a poor work environment characterized by job demands outweighing resources. Burnout in nursing is linked to absenteeism, turnover, depression, job dissatisfaction, and even suicidal ideation (Rosa et al., 2020).

          This article enlightened these changing practice considerations:  more work, fear surrounding safety and health, isolation, threats to livelihoods, risk or redeployment, and the unknown, unclear, and uninformed, new technology, and rising moral residue (Rosa et al., 2020). Needed changes for the rapid and intelligent investment in nursing at the levels of policy and leadership to optimize strategic workforce in all specialties and levels.  

Theoretical Framework Selection Used

          The components to review when beginning research include assumptions, operational concepts, and theory or model relationships (Gray et al., 2017). The framework used for supporting a research study’s theory is developing the hypothesis, a frame of reference for observation, concept definitions, research designs, interpreting, and generalizations. It serves as a guide to systematically identify relationships among variables (Weld et al., 2008).

Research Framework

          As applied to nursing burnout during the pandemic of Covid-19, the research framework is appropriate. It looks at the different stressors and changes throughout the nursing care of patients in real-time. Wellness initiatives evaluated to reduce nursing burnout and maintain healthy staff. Databases provide platforms for systemic research, including Medline, CINAHL, PRESPERO, and others.

Insights Gained 

          The problems acquired during Covid-19 provide insight into the neglect of self-care, lack of communication, poor quality and safety, and increased medical errors (Rosa et al., 2020). The estimate of burnout within the United States ranges from 35% to 45%, as the pandemic has exacerbated poor work environments (Rosa et al., 2020). 

           Investment in rapid and intelligent nursing is needed at policy and leadership levels to ensure strategic workforce optimization in all specialties and levels (Rosa et al., 2020).  The level of moral distress from emotional and spiritual exhaustion is the anguish that arises from knowing what needs to be done, yet unable to act on it due to constraints that imperil clinicians’ integrity and well-being.

Theory Application

          The clinical setting practice problem of nursing burnout is applied to any clinical setting as nursing is exponentially exposed to the public. These are some nursing strategies: value clinicians, communicate best practices, monitor, and promote clinician well-being, provide a supportive and blame-free work culture, enable cooperation and collaboration, and provide a central access point for Covid-19 information and updates.

References

Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier

Rosa, W. E., Schlak, A. E., & Rushton, C. H. (2020). A blueprint for leadership during COVID-19. Nursing Management, 8, 28. https://doi-org.ezp.waldenulibrary.org/10.1097/01.NUMA.0000688940.29231.6f

Weld, K., Padden, D., Ramsey, G., & Garmon Bibb, S. C. (2008). A framework for guiding health literacy research in populations with universal access to healthcare. Advances in Nursing Science, 31(4), 308-318.

EXAMPLE REPLY POST

The ethical challenges health care is faced with today have various laws, rules, regulations, laws, and ethical standards (Haahr et al., 2020). One of the major issues involves confidentiality, informed consent, and patient relationships, which is concerning in many health care organizations. Sabone et al. (2020) contended what is legal today might not be considered ethical, as the ever-present threat of being sued for negligence and malpractice is always at the forefront. There are still unresolved issues around when to get a minor’s parents involved about pregnancy. As we know, violating the patient’s confidentiality can hurt the patient and have legal and ethical consequences for the health care worker. As nurses, it is essential that we integrate ethical problem-solving and decision-making into our daily routine practice habits.

References

Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing Ethics, 27, 258-272. https://doi.org/10.1177/096973 3019832941

Sabone, M., Mazonde, P., Cainelli, F., Maitshoko, M., Joseph, R., Shayo, J., Morris, B., Muecke, M., Wall, B. M., Hoke, L., Peng, L., Mooney-Doyle, K., & Ulrich, C. M. (2020). Everyday ethical challenges of nurse-physician collaboration. Nursing Ethics, 27, 206-220. https://doi.org/10.1177/0969733019840753

ANOTHER REPLY SAMPLE

To review a research framework model allows the depiction of relationships and presents the intention of the study and what is tested (Gray, Grove, & Sutherland, 2017). Research questions and hypotheses shine light upon the theoretical framework of research. There can be theoretical framework to show possible relations, uncertain theories, or a philosophical viewpoint (Gray, Grove, & Sutherland, 2017, p.138). You brought forward new insights gained from Theoretical Domain framework with the use of the 33 behavior change theories. These allow interventions to be presented to support behavior changes (Smith et al., 2019). A unique visual approach to allow the portrayal of those relationships and interventions between the concepts for theoretical framework is the use of concept maps. This article is set up for a superb visual to allow further explanation of the Theoretical Domain framework, particularly with this involving long-term care.

References

Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research:

Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier

Smith, J.D., Corace, K.M., MacDonald, T.K., Fabrigar, L.R., Saedi, A., Chaplin, A., … & Garber, G.E. (2019).

Application of the Theoretical Domains Framework to identify factors that influence hand hygiene compliance in long-term care. Journal of Hospital Infection, 1010(4), 393-398.